Provider Demographics
NPI:1699897579
Name:ISSHAK IBRAHIM, SHERIF (MD)
Entity type:Individual
Prefix:
First Name:SHERIF
Middle Name:
Last Name:ISSHAK IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3053
Mailing Address - Country:US
Mailing Address - Phone:863-293-1191
Mailing Address - Fax:
Practice Address - Street 1:325 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4111
Practice Address - Country:US
Practice Address - Phone:863-293-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102341207RN0300X
AZ50724207RN0300X
FLME134640207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1023411Medicare PIN
AZZ178587Medicare PIN
CA0A1023410Medicare PIN